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Advances in Methods of Emergency Contraception

Successful Experience with the Strategic Approach in Romania – Dr Mihai Horga Directorate of Family & Social Assistance, Romania

TThe Strategic Approach methodology developed by the Department of Reproductive Health and Research of WHO is being used in 18 countries to strengthen their reproductive health programmes. An overview of the strategic approach with summary of experiences and guidelines for conducting assessments has already been published by RHR, WHO. A successful experience of the strategic assessment of Policy, Programme and Research issues related to pregnancy termination in Romania is highlighted. MMR was high in Romania prior to 1990 due to restrictive legislation and has been brought down post-1990 due to the liberalization of abortion laws. (Fig. 3.3.1). Figure 3.3.1 Evolution of maternal mortality in Romania Abortion rates have decreased, along with MMR due to unsafe abortions. (Fig. 3.3.2) Parts of a Strategic Assessment process included an assessment team,background paper, planning workshop, developing instruments, fieldwork and dissemination workshop. Figure 3.3.2 Evolution of abortion rates The Strategic Assessment team consisted of 19 members representing major stakeholders involved in RH. The team’s role included overall support for the process, development of the assessment and data collection instruments, fieldwork, data analysis, development of the assessment report and dissemination of the assessment results. Several abortion-related questions were asked. Major findings of assessment team revealed that abortion is still the most commonly-used method for fertility regulation in Romania, with a complication rate higher than in western countries and a weak link between abortion and contraception. Most abortions are done in private sector and illegal abortion is still a problem. Some of the weaknesses identified in abortion services at Romania were : (a) Generally, low-quality of care in abortion service provision, including flaws of the provider-patient interaction and lack of privacy and confidentiality. (b) Most abortions are performed by dilatation and curettage. STRATEGIC QUESTIONS • Why do women in Romania consider abortion to be the most important fertility regulation method? • What are the perspectives and the needs in terms of abortion, especially in relation with the use of contraception? • Are there any problems in terms of access to services for certain women and especially for young women, and if so, what are these problems? • What role does the private sector play in providing services? • What is the quality of care provided by the abortion services, including post-abortion contraception, and how can it be improved? • How can family planning services be best added to abortion services? • What strategies can be used in order to increase the use of contraception and decrease the need for abortion? • Is there a need to change current abortion methods and if so, what is the practical possibility to change them? • What are the priorities in terms of introducing new fertility regulation methods taking into consideration the needs and opinions of women, the capacity of service provision system and technologies that are currently available?

(c) Deficiencies in the abortion procedures, anaesthesia, and infection prevention practices.
(d) Deficiencies in organizing procedures in the abortion facilities, and in the reporting system, especially from the private sector

Some important actions have been taken following the assessment, including:

• Government decision on the strategy of rehabilitation of the obstetrics and gynaecology care in Romania that all public obstetrics gynaecology hospital departments will ensure safe and quality abortion services, including counseling and post-abortion contraception.
• The fee for abortion services cannot exceed a maximal amount set by the Ministry of Health and Family in order to avoid limiting women’s access to services and recourse to illegal abortion.
• Expansion of contraceptive services towards primary health-care level, especially in rural areas, training family physicians and nurses in contraceptive service provision, making free or subsidized contraceptives available to women and campaigns to change behaviour. Government purchase of contraceptives to be provided free of charge to eligible women.
• Inclusion of oral contraceptives and injectables on the list of drugs subsidized by the NationalHealth Insurance House by 65%

Following assessment, Framework for Action in Stage II was outlined. (Figure 3.3.3)

The following important steps were taken to improve the abortion services in Romania:

1. Standards, record-keeping and reporting system

Design, dissemination, implementation, and monitoring of standards, records, and reporting system for pregnancy-termination services, including post-abortion contraception and links with other reproductive health services was developed. This included designing standards and recommendations for pregnancy termination procedures, provider-patient interactions, counseling, privacy and confidentiality of the procedure and communication with the family physician.

2. Training of service-providers

Raise pregnancy termination and contraception service-providers’ knowledge and skills and change their behaviour by training physicians and nurses and students, with a focus on pregnancy prevention and interaction with patients.

3. Quality of services

Improve the quality of care for services provided in departments and clinics offering pregnancy termination,starting with a focus on the client-friendly concept, pre and post abortion counseling and development of model pregnancy termination services.

4. Introduction of improved technologies

The assessment findings led to the conclusion that the introduction of improved technologies in pregnancy termination services must be a priority. This included the use of vacuum aspiration up to ten weeks of gestation in all facilities providing abortion and use of medical abortion.

5. Improve policies and regulations

Need to sustain and improve policies governing pregnancy termination integrated in the morecomprehensive context, advocacy for reproductive health, and policies governing the funding and monitoring of pregnancy termination and contraception and reporting systems.

6. Information and education of the population

Information and education of the population with respect to modern contraception and abortion, healthy reproductive behaviour change activities, healthy lifestyles, education in schools and promotion of reproductive health messages by physicians, nurses, and pharmacists.